Temporomandibular Joint Disorder Treatment Product Applicability

Temporomandibular Joint Disorder Treatment + Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

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bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy

Temporomandibular Joint Disorder Treatment Policy Number: OCA 3.968 Version Number: 13 Version Effective Date: 01/01/17

Product Applicability

All Plan+ Products

Well Sense Health Plan New Hampshire Medicaid NH Health Protection Program

Boston Medical Center HealthNet Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options

only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary

The Plan considers medical and/or surgical (non-dental) treatment of a temporomandibular joint (TMJ) disorder to be medically necessary ONLY when the disorder is caused by or results in a specific medical condition. Examples of specific medical conditions include jaw fractures and/or dislocations and degenerative arthritis. Prior authorization is required. It will be determined during the Plan’s prior authorization process if the treatment of a TMJ disorder is considered medically necessary for the requested indication (and must be related to a specific medical condition). See the Plan’s policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment. Review the member’s applicable benefit

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documents available at www.bmchp.org for BMC HealthNet Plan members (or at www.SeniorsGetMore.org for Senior Care Options members) and www.wellsense.org for Well Sense Health Plan members for benefit coverage (including treatment guidelines and age-specific coverage) for the treatment of a TMJ disorder when the condition is related to a medical condition. Separate coverage is outlined in the member’s benefit documents for dental services (if dental services are covered for the Plan member). This medical policy ONLY includes guidelines for TMJ disorders related to a medical condition for medical and/or surgical (non-dental) treatment. See the Definitions section of this policy for a definition of TMJ disorders (including a list of symptoms commonly experienced with a TMJ disorder). TMJ syndrome (as defined in the Definitions section of this policy) is generally treated by a dentist. Verify the individual’s dental coverage (if dental coverage is available through the Plan or with another dental insurance carrier) to determine if the treatment of TMJ syndrome or a TMJ disorder NOT related to a medical condition is a covered dental service for the individual.

Description of Item or Service

Temporomandibular Joint (TMJ) Disorder Treatment: A variety of therapeutic services for the treatment of TMJ disorders, ranging from non-surgical pharmaceutical therapy, physical therapy, and/or mandibular orthopedic repositioning appliances, to surgical procedures such as dislocation reduction, open arthroplasty with implant, and vertical ramus osteotomy. TMJ disorder is a generic term used for any problem concerning the jaw joint. Injury to the jaw, temporomandibular joint or muscles of the head and neck may cause a TMJ disorder. Other causes include clenching of teeth, dislocation of the disc, osteoarthritis arthritis, rheumatoid arthritis, stress, and/or aging. The most common TMJ disorders are pain dysfunction syndrome, internal derangement, arthritis, and trauma. See the Definitions section of this policy for a definition of TMJ disorders (including a list of symptoms commonly experienced with a TMJ disorder) and a definition of TMJ syndrome.

Medical Policy Statement

The Plan considers the treatment of a TMJ disorder to be medically necessary ONLY when the disorder is caused by or results in a specific medical condition for medical and/or surgical (non-dental) treatment and the following applicable medical criteria are met and documented in the member’s medical record, as specified below in item A (for the initial medical evaluation) or item B (for treatment after the initial medical evaluation): A. Initial Medical Evaluation:

1. Prior authorization is NOT required for the initial medical evaluation to identify the underlying medical condition causing the TMJ disorder when conducted by the treating physician or a licensed independent practitioner practicing within the scope of the practitioner’s license (i.e., nurse practitioner or physician assistant) to diagnosis the medical condition when BOTH of the following criteria are met, as specified below in item a and item b:

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a. Initial medical evaluation is part of a new patient office visit (and is billed as such with the

appropriate CPT code and diagnosis code); AND b. The new patient office visit is conducted by a specialist with the expertise to evaluate the

symptoms of TMJ disorders related to jaw fracture, dislocation of jaw, and/or degenerative arthritis and renders a diagnosis (as specified in the Applicable Coding section of this policy and item B1 of this Medical Policy Statement section); OR

2. Prior authorization is REQUIRED for the initial medical evaluation for a TMJ disorder when

BOTH of the Plan criteria listed above in item A1a and item A1b are NOT met (using the criteria for treatment specified in item B below when the initial medical evaluation does require prior authorization).

B. Treatment After the Initial Evaluation:

Medical and/or surgical (non-dental) treatment for a TMJ disorder after the initial evaluation requires prior authorization. The TMJ disorder must be related to a medical condition and meet ALL of the following criteria, as specified below in items 1 through 3:

1. Specific medical condition eligible for treatment includes at least ONE (1) of the following, as

specified below in item a or item b:

a. Jaw fracture or dislocation;ⱡ OR

ⱡ Note: This criterion refers to a current fracture or acute dislocation. See the Limitations section of this policy for clinical guidelines for a TMJ disorder related to a previous fracture or dislocation of the TMJ.

b. Degenerative arthritis; AND

2. The medical condition is confirmed by diagnostic x-rays or other generally accepted diagnostic procedures used to diagnose a jaw fracture, jaw dislocation, and/or degenerative arthritis, including a computed tomography (CT) scan, magnetic resonance imaging (MRI), cephalogram (x-rays of jaws and skull), pantogram (x-rays of maxilla and mandible), tomograms or arthrograms; AND

3. Based on the treatment plan determined by the treating provider, the TMJ disorder is related to

a medical condition and requires medical and/or surgical (non-dental) treatment. EITHER the applicable criteria for non-surgical treatment are met or the applicable criteria for surgical treatment are met, as specified below in item a or item b:


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a. Criteria for Non-Surgical Treatment:

The criteria for non-surgical treatment (excluding dental services) are applicable ONLY when non-surgical treatment is requested and the non-surgical treatment is clinically appropriate, as determined by the treating provider. (Some medical conditions such as fractures would not require first-line, conservative/non-surgical treatment.) Covered first-line treatment is non-surgical and conservative and may include but is not limited to ANY of the following (or a combination of the following), as specified below in items (1) through (4): (1) Pharmacologic therapy such as anti-inflammatory, muscle relaxants, and/or

analgesics; OR (2) Physical therapy (excluding therapeutic treatment modalities listed in the Limitations

section of this policy such as dry needling, iontophoresis, ultrasound, and/or transcutaneous electrical nerve stimulation [TENS]); OR

(3) Use of mandibular orthopedic repositioning appliances (MORA); OR (4) Therapeutic injections (e.g. local anesthetic or corticosteroids); OR

b. Criteria for Surgical Treatment:

The criteria for surgical treatment are applicable ONLY when surgical treatment is requested and surgical treatment is clinically appropriate, as determined by the treating provider. Surgical treatment is covered when the TMJ disorder is related to a medical condition and ALL of the following criteria are met, as specified below in items (1) through (4): (1) Failure of non-surgical treatments (as specified above in item a) or conservative

treatment is not indicated for treatment (e.g., fractures or dislocations) or is contraindicated for the member’s medical condition, as determined by the treating provider; AND

(2) Continuing pain and functional disability (such as facial or pre-auricular pain,

significant intermittent or persistent limitation in jaw mobility, or joint locking, popping, or crepitus); AND

(3) Meniscus displacement documented on imaging; AND (4) Covered procedures when surgical treatment criteria are met include ANY of the

following, as specified below in items (a) through (f):


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(a) Arthrocentesis (e.g., for acute closed lock); OR (b) Arthroscopic surgery (e.g., for arthritis); OR (c) Intraoral vertical ramus osteotomy (IVRO) to correct internal derangements; OR (d) Manipulation for reduction of fracture or dislocation; OR (e) Open surgical procedure such as arthroplasty, condylectomy, meniscus or disc

plication, or disc removal; OR (f) TMJ arthroplasty will be performed with an FDA-approved prosthetic implant

(only) according to the FDA-approved indication for the implantation; FDA-approved devices include but are not limited to The Christensen Total Joint System (TMJ Implants), the TMJ Concepts System (TMJ Concepts), and the Biomet Microfixation prosthetic total joint (Biomet Microfixation).

Limitations

Separate coverage is outlined in the member’s benefit documents for dental services (if dental services are covered for the Plan member). This medical policy ONLY includes guidelines for TMJ disorders related to a medical condition for medical and/or surgical (non-dental) treatment. See the Definitions section of this policy for a definition of TMJ disorders (including a list of symptoms commonly experienced with a TMJ disorder). TMJ syndrome (as defined in the Definitions section of this policy) is generally treated by a dentist. Verify the individual’s dental coverage (if dental coverage is available through the Plan or with another dental insurance carrier) to determine if the treatment of TMJ syndrome or a TMJ disorder NOT related to a medical condition is a covered dental service for the individual.

Review the member’s applicable benefit documents available at www.bmchp.org for BMC HealthNet Plan members (or at www.SeniorsGetMore.org for Senior Care Options members) and www.wellsense.org for Well Sense Health Plan members for benefit coverage (including treatment guidelines and age-specific coverage) for the treatment of a temporomandibular joint (TMJ) disorder when related to a medical condition for medical and/or surgical (non-dental) services. The following Plan limitations include ANY of the following diagnostic services, treatments, and/or indications for treatment for a TMJ disorder, as specified below in items 1 through 3:

1. Plan Medical Director is required for treatment of a TMJ disorder when Plan criteria specified in the Medical Policy Statement section of this policy are not met and/or the disorder may be caused by a medical condition other than a jaw fracture, jaw dislocation, and/or degenerative arthritis (e.g., history of previous TMJ fracture and/or TMJ dislocation). When Plan criteria are not met, applicable clinical information must be submitted to the Plan Medical Director by the treating provider and include the member’s medical history, documentation of TMJ symptoms

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and duration of symptoms, results of physical examination, treatment to date (e.g., nonsteroidal anti-inflammatory drugs, jaw rest, muscle relaxation, physical therapy, and/or bite splinting), pertinent imaging test results documenting the medical condition causing the TMJ disorder, and the member’s individualized treatment plan. (The treatment of TMJ disorders or TMJ syndrome NOT related to a medical condition would be considered a dental service rather than a medical benefit.)

2. Any of the following services is NOT covered for the treatment of TMJ disorders for all applicable Plan products (including BMC HealthNet Plan members and Well Sense Health Plan members), as specified below in items a through p:

a. Treatment of a TMJ disorder that is NOT proven to be caused by or to result in a specific

medical condition (including but not limited to common TMJ disorders such as internal derangement and/or myofascial pain which are NOT caused by a medical condition); OR

b. Treatment for TMJ syndrome;Ɫ OR

ⱢNote: This medical policy ONLY includes guidelines for TMJ disorders related to a medical condition. TMJ syndrome is generally treated by a dentist. Verify the individual’s dental coverage [if dental coverage is available through the Plan or with another dental insurance carrier] to determine if the treatment of TMJ syndrome or a TMJ disorder NOT related to a medical condition is a covered dental service for the individual.

c. Acupuncture± (unless a covered benefit for the member for the specified indication);

±Note: Acupuncture treatment is a covered service for a Plan member ONLY when the treatment is included in the member’s product-specific benefit documents as a covered service for the specified indication. See the BMC HealthNet Plan member’s applicable benefit documents at www.bmchp.org (or at www.SeniorsGetMore.org for a Senior Care Options member) or at www.wellsense.org for a Well Sense Health Plan member for the most up-to-date information on benefit coverage for acupuncture treatment and other types of complementary and alternative medicine. Review the following Plan medical policy applicable for BMC HealthNet Plan members: Complementary and Alternative Medicine, Including Acupuncture Treatment, policy number OCA 3.194.

d. Appliances∞ such as mechanical stretching devices or devices to gain increased range of motion and/or improve functioning of the TMJ; OR

∞Note: Mandibular orthopedic repositioning appliance (MORA) may be covered when Plan criteria are met, as stated in the Medical Policy Statement section of this policy.

e. Biofeedback; OR


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f. Dental restorations/prostheses or orthodontic services, procedures, or supplies to adjust the height of teeth or in any other way restore occlusion, such as crowns, bridges or braces; OR

g. Dry needling alone or in combination with a stretching regimen used to reduce pain and

increase range of motion (ROM) in patients with TMJ pain; OR h. Electrical stimulation techniques including but not limited to electogalvanic stimulation,

percutaneous electrical stimulation (PENS), percutaneous neuromodulation therapy, and transcutaneous electrical nerve stimulation (TENS); OR

i. Electromyography (EMG) for the diagnosis of TMJ disorders or for other TMJ-related

indications; OR j. Intra-articular injection of hyaluronic acid (viscosupplementation); OR k. Iontophoresis using electricity to enhance the percutaneous absorption of a drug or

chemical ions; drugs used for iontophoresis to treat TMJ include lidocaine hydrochloride (a positive ion forming drug) and dexamethasone sodium phosphate (a negative ion forming drug); OR

l. Jaw tracking devices (i.e., devices have been developed to record and analysis the

mandibular movement); OR m. Laser therapy; OR n. Phonophoresis using ultrasound to enhance the delivery of topically applied drugs; OR

o. Ultrasonic Doppler auscultation/ultrasound imaging/sonogram for diagnosing disorders of the temporomandibular joint; OR

p. The use of a TMJ arthroplasty implant that is not FDA approved or the device is not used

according to for the specified FDA-approved indication.

3. See the Plan’s pharmacy policy, Botulinum Toxins - Botox®, Dysport®, Myobloc®, Xeomin® (policy number 9.106) for medically necessary indications for the use of botulium toxins for Plan members rather than guidelines included in this Plan medical policy. The Plan’s pharmacy policies are available at www.bmchp.org for BMC HealthNet Plan members and at www.wellsense.org for Well Sense Health Plan members. Pharmacy guidelines and a list of covered drugs are available at www.SeniorsGetMore.org for Senior Care Options members.


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4. Additional Guidelines for Well Sense Health Plan Members Enrolled in the NH Health Protection Program:

a. NH Health Protection Program members Age 19 or Age 20:

For a member enrolled in the NH Health Protection Program, benefit coverage for the medical and/or surgical (non-dental) treatment of a TMJ disorder related to a medical condition is limited to a member age 19 or age 20 (i.e., age 20 until the member’s 21st birthday on the date of service) when applicable Plan criteria are met.

b. NH Health Protection Program Members Age 21 or Older:

NH Health Protection Program members age 21 or older on the date of service are NOT covered for the treatment of TMJ disorders (including non-dental medical and/or surgical treatment) even when the TMJ disorder is related to a medical condition and applicable Plan criteria are met.

Definitions

Acupuncture Treatment: The insertion of metal needles through the skin at certain points on the body, with or without herbs, with an electric current and/or heat to the needles or skin. Acupuncture treatment may be used for pain relief or anesthesia, as an aid to persons who are withdrawing from dependence on substances or in recovery from addiction, or for other indications. Practiced in China and other Asian countries for thousands of years, acupuncture is one of the key components of traditional Chinese medicine. Biofeedback: A behavioral training program that is used to educate a person on the control of physiologic responses such as heart rate, blood pressure, skin temperature, and/or muscle tension. Biofeedback provides auditory, sensory, or visual information from physiological responses, enabling an individual to gain voluntary control over that response. Degenerative Arthritis: Also known as osteoarthritis and degenerative joint disease, degenerative arthritis is a type of arthritis caused by inflammation, breakdown, and eventual loss of the cartilage of the joints. Degenerative arthritis is the most common form of arthritis, usually affecting the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Dry Needling: An invasive procedure in which a solid filament needle is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle and may be used to treat temporomandibular joint pain. Dry needling is performed by western medical practitioners using acupuncture-type needles to treat the musculoskeletal and nervous systems based on modern neuroanatomy science; acupuncture falls within the scope of traditional Chinese medicine.

http://www.medicinenet.com/osteoarthritis/article.htm

http://www.medicinenet.com/arthritis/article.htm


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Internal Derangement of the Temporomandibular Joint (TMJ): Disruption within the internal aspects of the TMJ in which there is a displacement of the disc from its normal functional relationship with the mandibular condyle and the articular portion of the temporal bone. The condition is characterized by displacement of the intra-articular disc, results in clicking or popping sounds. The displacement of the articular disc does not always cause a mechanical obstruction. TMJ internal derangement may be painless or may be associated with pain, especially during function. The most common causes are trauma and/or chronic degenerative changes. A diagnosis of a displaced intra-articular disc with internal derangement of the TMJ is not an indication for treatment. If the disc restricts movement and causes pain, treatment may be required; however the displaced disc and symptom of pain can be totally unrelated. If a displaced disc is present with no pain, then no treatment is needed. If the displaced disc is accompanied by pain, the pain may subside with or without treatment. Myofascial Pain Syndrome (MPS): A chronic condition affecting the connective tissue (i.e., fascia) surrounding the muscles. MPS is characterized by pain and inflammation of the soft tissues of the body, typically caused by pressure on myofascial trigger points (MTPs), which are hyperirritable spots located in taut bands of skeletal muscle. MTPs cause regional, persistent pain, and decreased range of motion (ROM) in the affected muscles. MTPs may also cause tension headache, tinnitus, temporomandibular joint pain, decreased ROM in the legs, and low back pain. Percutaneous Electrical Nerve Stimulation (PENS): Therapy that combines the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS). PENS is performed with a few needle electrodes while PNT uses very fine needle-like electrode arrays that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue. PENS is similar in concept to TENS but differs in that needles are inserted either around or immediately adjacent to the nerves serving the painful area and are then stimulated with PENS. PENS is generally reserved for patients who fail to get pain relief from TENS. Unlike acupuncture, the placement of needles/location of stimulation with PENS is determined by proximity to the pain rather than the theories of energy flow that guide placement of stimulation for acupuncture. Percutaneous Neuromodulation Therapy (PNT): Therapy that combine the features of electroacupuncture and transcutaneous electrical nerve stimulation (TENS). PENS is performed with a few needle electrodes while PNT uses very fine needle-like electrode arrays that are placed in close proximity to the painful area to stimulate peripheral sensory nerves in the soft tissue. PNT is a variant of PENS in which fine filament electrode arrays are placed near the area that is causing pain. It is proposed that PNT inhibits pain transmission by creating an electrical field. Devices include but are not limited to: Percutaneous Neuromodulation Therapy™ (Vertis Neurosciences) and The Deepwave® Percutaneous Neuromodulation Pain Therapy System (Biowave). Temporomandibular Joint (TMJ): The area directly in front of the ear on either side of the head where the upper jaw (maxilla) and the lower jaw (mandible) meet. The joints are complex and are composed of muscles, tendons, and bones which are used when chewing, talking, and yawning.


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Transcutaneous Electrical Nerve Stimulation (TENS): The application of electrical stimulation to the surface of the skin on the area of pain or at a pressure point, creating a circuit of electrical impulses that travels along nerve fibers to relieve pain. Temporomandibular Joint (TMJ) Disorder: Also known as myofascial pain dysfunction and Costen’s syndrome, this is a group of complex disorders of the temporomandibular joint(s) causing pain and dysfunction of the jaw joint and muscles that control jaw movement. Treatment of TMJ disorder ranges from conservative to surgical, and the symptoms of TMJ disorder may include the following, as specified below in items 1 through 8:

1. Biting or chewing difficulty or discomfort 2. Clicking sound while chewing or opening the mouth 3. Dull, aching pain in the face 4. Earache

5. Grating sensation while chewing 6. Headache 7. Jaw pain or tenderness of the jaw 8. Reduced ability to open or close the mouth

Temporomandibular Joint (TMJ) Syndrome: Pain in the jaw joint with the following associated signs and symptoms: swelling, ear pain, tinnitus, hearing loss, muscle spasms, trouble swallowing, headache, dizziness, and/or locked jaw. Causes include disease (e.g., degenerative joint disease), trauma, wear and tear, or habits (such as nocturnal jaw clenching or teeth grinding). When the syndrome is a physical manifestation of psychological stress and no primary disorder of the joint itself is present, treatment is focused on behavioral modification (as opposed to joint repair). This medical policy only includes criteria for medical and/or surgical (non-dental) treatment for TMJ disorders caused by or the result of a medical condition. TMJ syndrome is generally treated by a dentist. Verify the individual’s dental coverage (if dental coverage is available) to determine if the treatment of TMJ syndrome NOT related to a medical condition is a covered dental service for the individual.

Applicable Coding

The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for

http://www.nlm.nih.gov/medlineplus/ency/article/003046.htm

http://www.nlm.nih.gov/medlineplus/ency/article/003024.htm


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Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service. Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Review the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member. See Plan reimbursement policies for Plan billing guidelines.

ICD-10 Diagnosis Codes Description: Diagnoses Requiring Prior Authorization for Any Treatment

M26.601 Right temporomandibular joint disorder

M26.602 Left temporomandibular joint disorder

M26.603 Bilateral temporomandibular joint disorder

M26.609 Unspecified temporomandibular joint disorder

M26.611 Adhesions and ankylosis of right temporomandibular joint

M26.612 Adhesions and ankylosis of left temporomandibular joint

M26.613 Adhesions and ankylosis of bilateral temporomandibular joint

M26.619 Adhesions and ankylosis of temporomandibular joint, unspecified side

M26.621 Arthralgia of right temporomandibular joint

M26.622 Arthralgia of left temporomandibular joint

M26.623 Arthralgia of bilateral temporomandibular joint

M26.629 Arthralgia of temporomandibular joint

M26.631 Articular disc disorder of right temporomandibular joint

M26.632 Articular disc disorder of left temporomandibular joint

M26.633 Articular disc disorder of bilateral temporomandibular joint

M26.639 Articular disc disorder of temporomandibular joint, unspecified side

M26.69 Other specified disorders of temporomandibular joint


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Clinical Background Information

Temporomandibular joint (TMJ) disorders generally fall into the following categories: traumatic abnormalities (e.g., jaw fracture, jaw dislocation), myofascial pain, internal derangement of the joint, and degenerative arthritis. Symptomatic TMJ dysfunction is estimated to affect 28 percent of the adult population, with a smaller percentage experiencing severe impairment. The typical patient with TMJ dysfunction is a female (including an individual born with female reproductive organs and/or with typical female karyotype with two [2] X chromosomes) aged 20-40 years who has experienced symptoms for 3-5 years due to the misdiagnosis of symptoms, particularly during childhood and adolescence.

According to the American Association of Oral and Maxillofacial Surgeons (AAOMS), orofacial pain due to a TMJ condition is less common in young children (than with teenagers and adults). Internal derangements and TMJ disorders other than congenital deformities (e.g., hemifacial microsomia) or acquired anatomical abnormalities (e.g., fractures, bony ankyloses) are very uncommon in young children. When painful TMJ conditions do occur, underlying psychopathologic factors are more frequent. When an operative procedure on the TMJ is required on a growing child for the treatment of a medical condition, the treating surgeon must provide both normal functioning anatomy and allow an environment in which normal growth and development of the mandible and face may occur (including the use of autogenous donor sites with growth potential when clinically appropriate) .

Myofascial pain is the most common TMJ disorder and involves discomfort or pain in the muscles that control jaw function. Internal derangement of the joint involves a displaced disc, dislocated jaw, or injury to the condyle. Degenerative arthritis refers to a group of inflammatory degenerative joint disorders that can affect the temporomandibular joints. Often there is no known cause for TMJ disorders and the progression is unclear. Symptoms worsen and ease over time. The clinical problem is complex, because TMJ dysfunction is multifactorial. A variety of pathologies may affect the TMJ, of which internal derangement is the most common. Causes of TMJ disorders are unclear but trauma to the jaw or temporomandibular joint causing fractures or dislocations and degenerative arthritis can contribute to the development of TMJ disorders. Treatments ranging from conservative to surgical depend upon the severity of the disorder. First-line therapy includes ice packs, avoidance of extreme jaw movements such as chewing gum and eating hard foods; medications such as analgesics, anti-inflammatories and muscle relaxants; gentle stretching exercises, physical therapy, mandibular orthopedic repositioning appliances and therapeutic injections. Some irreversible treatments have not been proven to be effective and may even worsen the problem. These may include orthodontics to change the bite, crown and bridge work, grinding the teeth and repositioning splints. Surgical treatments are used as a last resort when conservative measures have failed. Examples of surgical treatments include arthrocentesis, manipulation for reduction of fracture or dislocation, arthroscopic surgery, condylectomy, meniscus or disc plication, disc removal, and TMJ arthroplasty with prosthetic implants.


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At the time of the Plan’s most recent policy review, the Centers for Medicare & Medicaid Services (CMS) does not have clinical guidelines specifically for TMJ disorders. National coverage determination (NCD) 150.1 for manipulation states manipulation of the occipitocervical and/or temporomandibular regions of the head are covered for Medicare beneficiaries when indicated for conditions affecting those portions of the head and neck. Services related to the treatment of TMJ disorders (and corresponding clinical guidelines) may or may not be include an NCD or LCD, including but not limited to the following: NCD 160.7.1 for assessing patient's suitability for electrical nerve stimulation therapy (160.7.1) and NCD 160.13 for supplies used in the delivery of transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES). Verify CMS criteria in the applicable NCD, local coverage determination (LCD), and/or coverage guidelines in effect on the date of the prior authorization request for the medical condition causing the TMJ disorder and proposed medical and/or surgical treatment(s) for a Senior Care Options member.

References

Al-Baghdadi M, Durham J, Steele J. Timing interventions in relation to temporomandibular joint closed lock duration: a systematic review of ‘locking duration.’ Journal of Oral Rehabilitation. 2014. 41: 24-58. The American Academy of Orofacial Pain. Orofacial Pain: Guidelines for Assessment, Diagnosis and Management. Fourth Edition. 2013. American Association for Dental Research (AADR). Policy Statement: Temporomandibular disorders (TMD). Adopted 1996. Revised 2010. Reaffirmed 2015. Accessed at: http://www.aadronline.org/i4a/pages/index.cfm?pageid=3465 American Association of Oral and Maxillofacial Surgeons (AAOMS). Parameters of Care Version 5: Clinical Practice Guidelines for Oral and Maxillofacial Surgery. 2012. American Dental Association. Temporomandibular (Craniomandibular) Disorders. Practice Parameters. Adopted 1996. Revised 1997. http://www.ada.org/1958.aspx. American Society of Temporomandibular Joint Surgeons. Guidelines for Diagnosis and Management of Disorders Involving the Temporomandibular Joint and Related Musculoskeletal Structures. Revised 2001 Apr. Accessed at: http://astmjs.org/final%20guidelines-04-27-2005.pdf Centers for Medicare & Medicaid Service (CMS). National Coverage Determination (NCD) for Assessing Patient's Suitability for Electrical Nerve Stimulation Therapy (160.7.1). June 19, 2006. Accessed at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=174&NcaName=Cavernous+Nerves+Electrical+Stimulation+with+Penile+Plethysmography&ExpandComments=y&CommentPeriod=0&NCDId=63&ncdver=2&CoverageSelection=National&KeyWord=Electrical+Nerve+Stimulation&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAABAAEEAAAA%3D%3D&

http://www.aadronline.org/i4a/pages/index.cfm?pageid=3465

http://www.ada.org/1958.aspx

http://astmjs.org/final%20guidelines-04-27-2005.pdf

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCAId=174&NcaName=Cavernous+Nerves+Electrical+Stimulation+with+Penile+Plethysmography&ExpandComments=y&CommentPeriod=0&NCDId=63&ncdver=2&CoverageSelection=National&KeyWord=Electrical+Nerve+Stimulation&KeyWordLookUp=Title&KeyWordSearchType=And&list_type=ncd&bc=gAAAABAAEEAAAA%3D%3D&






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Centers for Medicare & Medicaid Service (CMS). National Coverage Determination (NCD) for Manipulation (150.1). Effective Date Not Posted. Accessed at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=3&ncdver=1&SearchType=Advanced&CoverageSelection=National&NCSelection=NCD&KeyWord=temporomandibular&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d& Centers for Medicare & Medicaid Service (CMS). National Coverage Determination (NCD) for Supplies Used in the Delivery of Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular Electrical Stimulation (NMES) (160.13). July 14, 1988. Accessed at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=151&ncdver=1&bc=AgAAQAAAAAAAAA%3D%3D& Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx Conti PC et al. The treatment of painful temporomandibular joint clicking with oral splints: a randomized clinical trial. J Am Dent Assoc. 2006 Aug;137(8):1108-14. Devaraj SD, Pradeep D. Internal Derangement of Temporomandibular Joint - A Review. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS). e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 13, Issue 3 Ver. II. March 2014. PP 66-73. Accessed at: http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue3/Version-2/S013326673.pdf EMedicine Health. Temporomandibular Joint (TMJ) Syndrome Topic Guide. Temporomandibular Joint (TMJ) Syndrome. Accessed at: http://www.emedicinehealth.com/temporomandibular_joint_tmj_syndrome/topic-guide.htm Emshoff R et al. Low-level laser therapy for treatment of temporomandibular joint pain: a double-blind and placebo-controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008 Apr;105(4):452-6. Frey DR et al. Effects of surgical mandibular advancement and rotation on signs and symptoms of temporomandibular disorder: a 2-year follow-up study. Am J Orthod Dentofacial Orthop. 2008 Apr;133(4):490.e1-8. Gonzalez-Perez LM, Infante-Cossio P, Granados-Nuñez M, Urresti-Lopez FJ. Treatment of temporomandibular myofascial pain with deep dry needling. Med Oral Patol Oral Cir Bucal. 2012 Sep; 17(5): e781–e785. Published online 2012 May 1. doi: 10.4317/medoral.17822. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3482522/ Guarda-Nardini L et al. A one-year case series of arthrocentesis with hyaluronic acid injections for temporomandibular joint osteoarthritis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Jun;103(6):e14-22.

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=3&ncdver=1&SearchType=Advanced&CoverageSelection=National&NCSelection=NCD&KeyWord=temporomandibular&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&





https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=151&ncdver=1&bc=AgAAQAAAAAAAAA%3D%3D&

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=151&ncdver=1&bc=AgAAQAAAAAAAAA%3D%3D&

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue3/Version-2/S013326673.pdf

http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue3/Version-2/S013326673.pdf

http://www.emedicinehealth.com/temporomandibular_joint_tmj_syndrome/article_em.htm

http://www.emedicinehealth.com/temporomandibular_joint_tmj_syndrome/article_em.htm

http://www.emedicinehealth.com/temporomandibular_joint_tmj_syndrome/topic-guide.htm

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3482522/


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Hall HD et al. Prospective multicenter comparison of 4 temporomandibular joint operations. J Oral Maxillofac Surg. 2005 Aug;63(8):1174-9. Hayes Medical Technology Directory. Dry Needling for Myofascial Pain in Adults. Winifred Hayes, Inc. December 4, 2013. Annual Review November 11, 2015.

Hayes Search & Summary. Jaw Dynasplint System (Dynasplint) for Treatment of Mandibular Hypomobility. Winifred Hayes, Inc. April 7, 2016. Hobeiche J et al. Arthroscopy vs. open-joint surgery for the management of internal derangement of the temporomandibular joint: a retrospective study comparing female subjects from two centers. J Contemp Dent Pract. 2008 Mar 1;9(3):48-55.

Khan AN. Imaging of Meniscus Abnormalities in the Temporomandibular Joint. Medscape Reference. Drugs, Diseases & Procedures. March 14, 2013. Accessed at: http://emedicine.medscape.com/article/385129-overview List T, Axelsson S. Management of TMD: Evidence from Systematic Reviews and Meta-analysis. J Oral Rehab. 2010, 37; 430-451. Luther F, Layton S, McDonald F. Orthodontics for treating temporomandibular joint (TMJ) disorders. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD006541. Manfredini D. Current Concepts on Temporomandibular Disorders. Quintessence Publishers 2010. Manfredini D, Piccotti F, Guarda-Nardini L. Hyaluronic acid in the treatment of TMJ disorders: a systematic review of the literature. Cranio. 2010 Jul;28(3):166-76. PMID: 20806734 DOI: 10.1179/crn.2010.023. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/20806734 Martins WD, Ribas Mde O, Bisinelli J, França BH, Martins G. Recurrent dislocation of the temporomandibular joint: a literature review and two case reports treated with eminectomy. Cranio. 2014 Apr;32(2):110-7. PMID: 24839722. DOI: 10.1179/0886963413Z.00000000017. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/24839722 MedicineNet.com. Definition of Degenerative Arthritis. May 13, 2016. Accessed at: http://www.medicinenet.com/script/main/art.asp?articlekey=2931 Mehta NR. Arthritis of the Temporomandibular Joint (TMJ). Merk Manual Professional Version. December 2014. Accessed at: http://www.merckmanuals.com/professional/dental-disorders/temporomandibular-disorders/arthritis-of-the-temporomandibular-joint-tmj

http://emedicine.medscape.com/article/385129-overview

http://www.ncbi.nlm.nih.gov/pubmed/20806734

https://www.ncbi.nlm.nih.gov/pubmed/24839722

http://www.medicinenet.com/script/main/art.asp?articlekey=2931

http://www.merckmanuals.com/professional/dental-disorders/temporomandibular-disorders/arthritis-of-the-temporomandibular-joint-tmj

http://www.merckmanuals.com/professional/dental-disorders/temporomandibular-disorders/arthritis-of-the-temporomandibular-joint-tmj


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Mehta NR. Internal Temporomandibular Joint Derangement. Merk Manual Professional Version. December 2014. Accessed at: http://www.merckmanuals.com/professional/dental-disorders/temporomandibular-disorders/internal-temporomandibular-joint-derangement Mina R, Melson P, Powell S, Rao M, Hinze C, Passo M, Graham TB, Brunner HI. Effectiveness of dexamethasone iontophoresis for temporomandibular joint involvement in juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2011 Nov;63(11):1511-6. doi: 10.1002/acr.20600. Accessed at: http://www.ncbi.nlm.nih.gov/pubmed/22034112 Monje-Gil F, Nitzan D, Gonzalez-Garcia R. Temporomandibular joint arthrocentesis. Review of the literature. Med Oral Patol Oral Cir Bucal. 2012 July; 17(4): e575–e581. Accessed at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476018/

National Institutes of Health. National Institute of Dental and Craniofacial Research. TMJ Disorders. NIH Publication No. 13-3487. January 2013. Accessed at: http://www.nidcr.nih.gov/oralhealth/Topics/TMJ/TMJDisorders.htm Politi M et al. High condylectomy and disc repositioning compared to arthroscopic lysis, lavage, and capsular stretch for the treatment of chronic closed lock of the temporomandibular joint. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Jan;103(1):27-33. Rigon M, Pereira LM, Bortoluzzi MC, Loguercio AD, Ramos AL, Cardoso JR. Arthroscopy for Temporomandibular Disorders. Cochrane Database System Review. 2011, May 11;(5):CD006385. Scivani SJ, Keith DA, Kaban LB. Temporomandibular Disorders. NEJM. 2008, 359:2693-705. Schiffman EL et al. Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. J Dent Res. 2007 Jan;86(1):58-63. The TMJ Association, Ltd. Displaced TMJ Disc. December 25, 2013. Accessed at: http://www.tmj.org/site/page?pageId=191 Truelove E et al. The efficacy of traditional, low-cost and nonsplint therapies for temporomandibular disorder: a randomized controlled trial. J Am Dent Assoc. 2006 Aug;137(8):1099-107.

Tsai V. Temporomandibular Joint Syndrome. Medscape Reference. Drugs, Diseases & Procedures. January 13, 2012. Accessed at: http://emedicine.medscape.com/article/809598-overview U.S. Food and Drug Administration (FDA). Medical Devices. Device Approvals, Denials and Clearances. Accessed at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/

http://www.merckmanuals.com/professional/dental-disorders/temporomandibular-disorders/internal-temporomandibular-joint-derangement

http://www.merckmanuals.com/professional/dental-disorders/temporomandibular-disorders/internal-temporomandibular-joint-derangement

http://www.ncbi.nlm.nih.gov/pubmed/22034112

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476018/

http://www.nidcr.nih.gov/oralhealth/Topics/TMJ/TMJDisorders.htm

http://www.tmj.org/site/page?pageId=191

http://emedicine.medscape.com/article/809598-overview

http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/


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Original Approval Date

Original Effective Date* and Version

Number Policy Owner Approved by

Regulatory Approval: N/A Internal Approval: 09/09/08: MPCTAC 09/30/08: UMC 10/22/08: QIC

01/01/09 Version 1

Medical Policy Manager as Chair of Medical Policy, Criteria, and Technology Assessment Committee (MPCTAC) and member of Quality Improvement Committee (QIC)

MPCTAC, QIC, and Utilization Management Committee (UMC)

*Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Heath Plan New Hampshire Medicaid Product(s): 01/01/13


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Policy Revisions History

Review Date Summary of Revisions

Revision Effective Date and Version

Number

Approved by

09/22/09 No criteria changes. Updated references.

Version 2 09/22/09: MPCTAC 10/28/09: QIC

09/01/10 No changes to criteria. Updated references and coding.


09/01/11 Updated limitations and references. Version 4 09/21/11: MPCTAC 10/26/11: QIC

07/01/12 References updated, revised language in the Applicable Coding section, and deleted four-digit diagnosis code 524.6.


07/01/13 Review for effective date 11/01/13. Updated references. Added criteria for medical evaluation of TMJ disorders. Reformatted, revised, and added examples in the Medical Policy Statement section. Added definition for temporomandibular joint syndrome. Deleted duplicate text in Clinical Background Information section.

11/01/13 Version 6

07/17/13: MPCTAC 08/15/13: QIC

07/29/12 Off cycle review for Well Sense Health Plan, revised Description of Service, reformatted the Medical Policy Statement, revised references.


01/30/14 Off cycle review for effective date 04/01/14. Added ICD10 diagnosis code equivalents of existing ICD9 diagnosis codes.


09/01/14 Review for effective date 01/01/15. Revised language in the Limitations section related to benefit coverage. Revised medical criteria in the Medical Policy Statement and Limitations sections. Updated references.

01/01/15 Version 9

09/17/14: MPCTAC 10/08/14: QIC

09/01/15 Annual review for effective date 01/01/16. Revised the list of applicable products, including removing Commonwealth Care, Commonwealth Choice, and Employer Choice from the list of applicable products because the products are no longer available.

01/01/16 Version 10

09/16/15: MPCTAC 10/14/15: QIC


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Policy Revisions History

Revised criteria in the Medical Policy Statement and Limitations sections. Updated Clinical Background Information and References sections.

11/25/15 Review for effective date 01/14/16. Revised language in the Applicable Coding section.

01/14/16 Version 11

11/25/15: MPCTAC (electronic vote) 12/09/15: QIC

09/01/16 and 09/28/16

Review for effective date 01/01/17. Removed ICD9 diagnosis codes. Updated Summary, Description of Item or Service, Definitions, Clinical Background Information, References, and Reference to Applicable Laws and Regulation. Revised criteria in the Medical Policy Statement and Limitations sections. Administrative changes made to clarify language related to gender.

01/01/17 Version 12

09/21/16: MPCTAC 09/30/16: MPCTAC (electronic vote) 10/12/16: QIC

12/05/16 Industry-wide change to applicable ICD-10 diagnosis codes for temporo-mandibular joint disorder effective 01/01/17.

01/01/17 Version 13

Not applicable because industry-wide revisions to ICD-10 diagnosis codes.

Last Review Date

12/05/16

Next Review Date

09/01/17

Authorizing Entity

QIC

Other Applicable Policies

Medical Policy - Complementary and Alternative Medicine, Including Acupuncture Treatment, policy number OCA 3.194 Medical Policy - Medically Necessary, policy number OCA 3.14 Pharmacy Policy - Botulinum Toxins - Botox®, Dysport®, Myobloc®, Xeomin®, policy number 9.106


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Reference to Applicable Laws and Regulations

78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

Disclaimer Information: +

Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs.

Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members.

The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

Temporomandibular Joint Disorder Treatment Product Applicability

Documents